Recent years have witnessed great advances in the neuroimaging field that permitted the elaborated evaluation of the brain structure and, most importantly, the complex central activity that takes place in humans at rest and during different types of functional challenges or cognitive activities. Such functional and structural studies provided fundamental information that when correlated with clinical symptoms brought better understanding for the cortical and subcortical mechanisms related to chronic pain syndromes. With regard to primary headaches, most of the MRI-based neuroimaging studies explored the pathophysiology of migraine and its related signs and symptoms such as pain severity, nausea, phonophobia, photophobia, and allodynia. Considering the unique cyclic characteristic of the disease, migraine research offers additional opportunities and logistic challenges including the study of patients during and outside their attacks (ictal and interictal phases, respectively), the increased sensitive to stimuli from the environment, and response to treatment. More recent studies using positron-emission tomography (PET) have provided novel clues at molecular level of major endogenous modulatory systems that could play an important role in the development and maintenance of migraine and other chronic pain states. For instance, molecular neuroimaging has showed in vivo that there is a significant dysfunction in endogenous mu-opioidergic and dopaminergic mechanisms during migraine attacks and allodynia, as well as neuropathic pain. In this chapter, we discuss novel discoveries using neuroimaging, including the role of central molecular mechanisms in migraine/pain suffering and treatment.

Our understanding of brain abnormalities in headache syndromes has greatly improved with the use of advanced neuroimaging methods. Neuroimaging allows for the noninvasive examination of brain structure and function using modalities such as magnetic resonance imaging (MRI). Measures of brain structure include those that can assess gray matter volume or thickness and white matter microstructure, whereas measures of brain function include those that assess brain activity and connectivity in patients compared to controls. While most studies in the headache literature have examined episodic headache disorders, there has been a recent push toward understanding neuroimaging-based brain abnormalities associated with chronic daily headache (CDH) to gain insight into its underlying pathophysiology. This chapter focuses on studies that have primarily used MRI methods to assess structural and functional brain abnormalities in CDH. These findings are discussed in the context of clinical symptoms and other chronic pain disorders. We conclude with a discussion on future directions for neuroimaging research in CDH.

The twentieth century was characterized by great discoveries in medical sciences, which enhanced our knowledge of mechanisms of disease and allowed for the development of pharmacological therapies to treat a large number of pathologies. During the same period, striking advances were accomplished in the pain field, particularly after the introduction of the concept of pain as a complex phenomenon rather than a simple sensation or a mere symptom. Moreover, at least part of the brain mechanisms related to such a complex experience has been revealed over the last decades with the advance of the neuroimaging field. Nonetheless, adequate pain control, especially in chronic pain patients, is still considered a challenge for clinicians worldwide. In this context, tDCS emerges as a promising mode to provide noninvasive modulation of dysfunctional neural networks present in chronic pain. Indeed, the results of several studies suggest that tDCS can produce long-lasting pain relief in different chronic pain syndromes, including migraine, fibromyalgia, and neuropathic pain. Nevertheless, it is still necessary to establish the most suitable protocols for each chronic pain disorder. Moreover, it is imperative to reveal the neuromechanisms related to tDCS-induced analgesia.

Chronic head and facial pain is a multifaceted experience for patients, as it can pervasively affect the ability to function and ultimately hinder quality of life. Multidisciplinary approaches, including psychological and psychiatric interventions, for headache and facial pain are often necessary for successful treatment. Mood and anxiety symptoms, as well as deleterious health behaviors, can derail appropriate self-management, which then negatively affects medical management. This chapter will review cognitive-behavioral interventions, relaxation/biofeedback training, operant learning theory, the role of family support, and psychotropic medication options that can enhance health coping and effective head and facial pain management.

Comprehensive pain assessment and treatment models incorporating a biopsychosocial approach have evolved over decades. Recent guidelines and evidence-based recommendations advocate assessment along multiple dimensions of the pain experience—beyond demographic information or pathophysiological status—to include personality variables, cognitions and beliefs, sociocultural variables, learning, and emotional reactivity. Individual differences in these psychosocial experiences contribute significantly to a patient’s perception of pain and ultimately the effectiveness of treatment. A thorough psychological assessment process is broken down into three areas: (a) the interview, (b) behavioral observations, and (c) standardized testing. The “Why, Where, How, When, and What” of conducting such an assessment is detailed in this chapter. Recommended strategies and validated questionnaires are reviewed. In all cases, chronic pain should be considered as complex, dynamic, and contextually sensitive. Even in the absence of a trained pain psychologist, the patient-oriented health-care provider can obtain valuable information and insight which can help guide the biopsychosocial management of the patient with head and/or facial pain.

Chronic pain is a complex disorder to which medical and psychological factors both contribute and react. While there are numerous chronic pain conditions, they share certain experiences. This review examines some of the psychological factors that are common to the pain experience and some of the psychologically-based treatments that have been utilized in conduction with medical treatments for pain. In light of the fact that there is not yet a “gold standard” in this regard, it ends with the challenge to develop coherent and effective multi-model treatments that draw upon the successes that have been demonstrated so far.

Chronic pain is a major cause of human suffering and impairment in function, affecting not only individuals, but also families, productivity in the workplace and society. Selected mechanisms involved in the transformation of acute pain into chronic debilitating pain are discussed. Two cases, one of a patient with chronic migraine and another case of a sufferer of back pain are presented in detail. The multi-level Pathways Model is applied to each case. The patient with migraine had a history of sexual abuse and met criteria for major depressive disorder. The example chosen for low back pain is that of a married man whose wife is emotionally and physically ill. He is stuck in past memories of a highly successful period of his life when he was a high school star athlete. Both patients were able to reduce pain, but perhaps even more importantly, they acquired healthier lifestyle behaviors, learned coping skills, and lessened symptoms of anxiety and depression. Although the interventions did not cure their pain, their suffering from chronic pain decreased and their ability to function in their personal world improved.

Recent human and animal studies provide growing evidence that vagal nerve stimulation (VNS) can deliver strong analgesic effects in addition to providing therapeutic efficacy in the treatment of refractory epilepsy and depression. Analgesia is potentially mediated by vagal afferents that inhibit spinal nociceptive reflexes and transmission and have strong anti-inflammatory properties. The purpose of this review is to provide pain practitioners with an overview of VNS technology and limitations. It specifically focuses on clinical indications of VNS for various chronic pain syndromes, including fibromyalgia, pelvic pain, and headaches. We also present potential mechanisms for VNS modulation of chronic pain by reviewing both animal and human studies.

In this paper, I analyze the illness stories narrated by a mother and her 13-year-old son as part of an ethnographic study of child chronic pain sufferers and their families. In examining some of the moral, relational and communicative challenges of giving an account of one’s pain, I focus on what is left out of some accounts of illness and suffering and explore some possible reasons for these elisions. Drawing on recent work by Judith Butler (Giving an Account of Oneself, 2005), I investigate how the pragmatic context of interviews can introduce a form of symbolic violence to narrative accounts. Specifically, I use the term “genre of complaint” to highlight how anthropological research interviews in biomedical settings invoke certain typified forms of suffering that call for the rectification of perceived injustices. Interview narratives articulated in the genre of complaint privilege specific types of pain and suffering and cast others into the background. Giving an account of one’s pain is thus a strategic and selective process, creating interruptions and silences as much as moments of clarity. Therefore, I argue that medical anthropologists ought to attend more closely to the institutional structures and relations that shape the production of illness narratives in interview encounters.